Sunday, April 29, 2012

Water Equals Life

We hiked to the top of Jebel mountain today. On the outskirts of Juba, this stunning rock formation (granite, I think) gives a pleasant break to the eye after the flat terrain of Juba proper. It was cool and drizzly, and at the top I could close my eyes and just feel the wind and rain on my face and not hear a single car, dog, or generator. It was one of the nicest moments so far in Juba.

I went to the hospital after dinner to check up on a patient that was suffering from an asthma attack. Reports throughout the day over the phone from the South Sudanese doc in training was that she was receiving proper treatment but not getting better. I gave him some additional suggestions over the phone to try to relax the tight airways in her lungs in order for her to breathe easier and asked that the on call doc call me later to see how she was doing. When I didn't hear back, I came in to see how she was responding.

As soon as I got on the ward, I could tell that she was improving. She was receiving albuterol by inhaler (attached to a water bottle as a makeshift spacer), IV hydrocortisone to decrease the inflammation, and had just received a loading dose of magnesium sulfate (something they aren't used to giving but we are introducing as a drug that can help patients in status asthmaticus). There isn't any ipratropium around to compliment the albuterol, and there is an unfortunate practice of using aminophylline, a drug that has a narrow therapeutic window (you give a little too little, and it's not very helpful; a little too much, and you get dangerous side effects). We don't use it anymore in the US. I showed the patient and caregiver how to better administer the albuterol, had the intern update the medication plan for the night, and was wrapping up until the more senior doc called me over to see another patient.

This young woman was in clear distress, breathing fast with a rapid and weak pulse. The blood pressure was low, and the oxygen level in her blood was only 70% of what it should be. She was slowly receiving IV saline through a small IV in her left arm. Her hands were cool and clammy, and she was confused. I knew that due to a probable bacterial infection in her blood, her blood vessels were leaky and she was not getting rid of waste products and getting oxygen to her tissues. She had received antibiotics, but that was only part of the treatment. She needed fluids, and she needed them fast. No matter what we tried, we couldn't get IV access. We really could have used an intraosseus needle, a quick way to get fluid into the bone marrow and then into circulation. We also needed high flow oxygen, and not a half functioning oxygen machine with partially cleaned tubing that had already been used on countless patients. We also needed a ventilator machine, a way to check labs during the night, antibiotics that were not counterfeit, staff that realize that two IVs are needed stat on a patient with a systolic BP of 85 and a pulse of 150. We needed her to present earlier in her illness. Among other things.

Her femoral pulse became erratic, her breathing stopped, and then her heart stopped. It still feels like I'm giving up by not starting CPR. But without a ventilator, without a defibrillator, without a team of nurses and docs that can manage an intubated patient, there is no reason to start chest compressions.

Patients die so often here. I can barely think of a handful of patients that have died during my ER shifts in the States, and none of which died due to inability to get fluids into them.

From this loss, I will push to get intraosseus needles sent from the US to be available on the ward, and we will make sure there is a policy that places two IVs in any patient that is tachycardic and hypotensive.

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